Tribal Science has now been out on the bookshelves for an entire month. I’m awaiting news on how well it’s doing, yet the handful of reviews it’s received – not to mention informal word-of-mouth feedback – have been pleasantly encouraging.
My local paper ran a relatively lengthy review, which for the most part was positive. Yet there was one thorn on this rose which stuck a little.
Now, there are always two ways to handle criticism – as an anabolic exercise, where growth and learning is the outcome…and tantrums. Tantrums are rarely good, so this is an opportunity worth unwrapping.
The reviewer took fair exception to my statement, ‘Disease exists within a tribal construct, as a difference between mere individual variation and social dysfunction.’ It wasn’t so much that he disagreed with it, but rather that he felt it was a meaningless statement worthy of comparison with Alan Sokal’s famous journal paper.
I have to admit it’s possible I completely misread my potential audience by making a claim without giving due consideration to prior knowledge or beliefs, therefore not presenting adequate reasoning.
It’s a rather heavy statement to make, in hindsight. In my western, post-industrial, scientifically-appreciative culture, disease is a relatively simple concept. It’s something that makes you feel unwell in some way. Some diseases are bad enough to kill you, and others make you a little grumpy and uncomfortable. But if you don’t feel an appropriate level of goodness…for all purposes, we can say you’ve got a disease of some sort.
Unfortunately, I take my objections to this conventional view so much for granted, accusations of pseudoscience come as a surprise. And, of course, they shouldn’t.
Stating that disease is a social construct smacks so much of extreme post-modernism, it makes sense that anybody with a passion for science is going to bristle. It’d be as ludicrous as believing a person could be both alive and dead, depending only on who you ask.
Yet while disease is objectively a feature of biological functionality, functionality is subjectively related directly to the environment. Including the social environment. In the very least, it’s a functionality that reduces a perception of well being in some way, which is determined by the behaviour and beliefs of those around you.
Being lactose intolerant makes no difference if you’re in a community that doesn’t drink milk. It’s a variation of no real consequence. If everybody relies on it for its sustenance, you’re in a bit of trouble – your variation in function could spell your demise.
Nowhere is this definition of disease more important than in mental health. Variations in behaviour (which unless you’re a dualist can be considered to be strictly a condition of one’s neurology) can be a hindrance to that sense of well being. Depression, anxiety attacks, and even ‘dubious’ dispositions such as Attention Deficit and Hyperactivity Disorder are directly related to human interactions. In Japan, the condition ‘hikikomori’ describes an acute withdrawal from society, and is rapidly coming to be viewed as much of a problem as depression is in the west. While there might well be physiological similarities between it and anxiety in the west, treating them as synonymous conditions risks missing subtelties in their etiology and potential treatments.
Of course, some things are considerably universal. Being unable to contribute to the community because you’re laid up in bed with a fever, in agony, is desired as much by some Polynesian fisherman as it is by a Japanese businessman. But what if you’re laid up in a hut because you’re menstruating? Few would consider this to be a disease given so many women ‘suffer’ from this uncomfortable period, yet if this same variation in functioning existed in just a minority, it would be indistinguishable from the western perception of a disease and would result in the same medical behaviours.
American medical anthropologist Allan Young describes disease as;
a kind of behavior which would be socially unacceptable (because it involves withdrawal or threatened withdrawal from customary responsibilities) if it were not that some means of exculpation is always provided.
Young, A. (1976), Some Implications of Medical Beliefs and Practices for Social Anthropology, American Anthropologist, New Series, Vol. 78, No. 1 pp. 5-24
Similarly, historian Charles Rosenberg claims;
[d]isease is at once a biological event, a generation-specific repertoire of verbal constructs reflecting medicine’s intellectual and institutional history, an aspect of and potential legitimation for public policy, a potentially defining element of social role, a sanction for cultural norms, and a structuring element in doctor/patient interactions.
Rosenberg, C., (1989) Disease in History: Frames and Framers, The Milbank Quarterly, Vol. 67, Suppl.1
In terms that aren’t so fancy, when your body functions in a way that is defined by your culture as intolerable – whether it’s experiencing a certain level of discomfort or being unable to contribute or interact in an acceptable fashion – the community behaves as if you’ve got a disease. Culpability is reduced. You’re pitied, not punished. A ritual is enacted that attempts to alleviate the symptoms or return functionality.
This is most notable in how conditions are treated when they aren’t labeled as diseases. When drug dependency is defined as a disease there is a perception of reduced responsibility, for instance. ‘Insanity’ can be entered as a defence for unacceptable behaviour, making the difference between a sentence in a prison and resources being dedicated to your rehabilitation in a mental health facility.
Yet disease is such a staunch biophysical concept in our society, we find it difficult to peel away the layers and question what determines an acceptable level of discomfort, an acceptable physical challenge, an acceptable interaction.
It’s an important question to ask when limited resources are devoted to repairing biology viewed as faulty, when a pill is popped for a dysfunctional child, or when we struggle over whether an alcoholic deserves derision or a helping hand. Yet it deserves more than a passing line in a book, as well, especially without sufficient explanation.